San Francisco Health Care Security Ordinance

In 2006, San Francisco passed its Health Care Security Ordinance (HCSO), which requires employers with 20 or more employees to spend an amount hourly on health care expenditures for every employee who has been employed more than 90 days, working at least 8 hours a week.  This law applies to employers operating in San Francisco, regardless of their headquartered location.  Additionally, the law uses the overall number of employees associated with an employer, therefore, employees working outside of San Francisco are calculated when determining the size of an employer with regards to this ordinance.

There is lower tier rate for employers between 20 – 99 employees, and a higher rate for those over 100 employees (see chart below).  The rate increases annually with the Consumer Price Index (CPI), and the increase is posted on the Office of Labor Standards Enforcement (OLSE) website.  OLSE is the enforcement agency for this law (as well as paid sick leave, minimum wage, paid parental leave, etc.), which requires annual reporting of health care expenditures and quarterly acknowledged payments for health care expenditures.  The required hourly spending requirement must be allocated toward health-related benefits, which can include health insurance and other private sector options, or paying into the City Option.  The City Option is a program where an employer pays their hourly spending requirement for all or some of their employees to the City for them to manage their employees’ healthcare funds.  The City Option is not health insurance and therefore, does not satisfy the Employer Mandate for a business subject to the Affordable Care Act.

 Employer Size Number of Employees  2018 Expenditure Rate  *NEW 2019 Expenditure Rate
 Large All employers w/100+ employees  $2.83 per hour payable  $2.93 per hour payable
 Medium Businesses w/20-99 employees & Nonprofits w/50-99 employees  $1.89 per hour payable  $1.95 per hour payable
 Small Businesses w/0-19 employees & Nonprofits w/0-49 employees  Exempt  Exempt

Amendments to the Health Care Security Ordinance

In 2014 the San Francisco Board of Supervisors changed the HCSO to ensure that all healthcare expenditures are irrevocable, phasing them to 100 percent irrevocable in 2017 and every year thereafter. While the original intent of the legislation was aimed at stopping unused Health Reimbursement Account (HRA) funds from returning to the employer, a by-product of the change now impacts the ability of employers with self-insured/self-funded plans from being able to use the COBRA premium rate for their spend calculation.

As of September 2017, the Office of Labor Standards Enforcement (OLSE) determined that the COBRA premium rate is less than the required spend amounts under HCSO and now that all expenditures are deemed irrevocable, using the COBRA premium calculation is not compliant with the law. The new rule for HCSO will require that employers with self-funded plans will need to decide whether to stay the course or change their calculation solely to the 2018 mandated spends:

  • $1.89 for employers with 20 – 99 employees
  • $2.83 for employers with 100 or more employees.

Irrevocability means that 100% of the mandated spend must be spent, regardless of whether insurance is being provided.  Therefore employers are required to meet an hourly spend level — so even if an employer is paying for health insurance for an employee, if the amount of the insurance premium averages to less than the calculated hourly spend for that employee, the employer is expected to spend the difference on another healthcare product.

Please visit our Vendor Directory to find partners that can help you and your business with the HCSO requirement.

Some options include:

OrderUp Health: NFP provides an alternative option with OrderUp Health, giving owners a better way to satisfy the San Francisco Health Care Security Ordinance (HCSO) and reduce healthcare costs. The OrderUp Health program provides comprehensive health-center based services including primary care, physical therapy, vision and behavioral health.

For Employers

  • Cost is no more than your required HCSO Spend
  • No additional or administrative fees
  • HCSO Consulting services included
  • HCSO Annual Reporting Preparation
  • Quarterly Spend Auditing with refunds for overpayment
  • Easy 3 Step Implementation process

For Employees

  • Member’s Only Access to State-of-the-Art Primary Care & Wellness facilities
  • No copays or deductibles
  • Unlimited Visits
  • Prescription Drugs at No Charge (150 of the most commonly prescribed generic medications)
  • No fee Mental Health, Physical Therapy and Acupuncture services
  • Lyft discount codes provided for transportation to and from appointments

For more information please reach out to Jenna Johnson –

In 2017, GGRA launched a partnership with Dignity Health GoHealth Urgent Care to offer our members an HCSO compliant plan, specifically focused on those employees who work between 8 and 20 hours a week in San Francisco. The plan was created in light of full irrevocability as an alternative to simply paying into the City Option. For more information, please click here.

Health Reimbursement Accounts

Prior to 2014, health reimbursement accounts (HRAs) covered a wide range of medical expenses, but due to the market reforms related to the Affordable Care Act, HRAs are now considered excepted benefits (see the OLSE’s FAQs for full information).  Unspent funds placed in HRAs can revert back to the employer after 24 months.  However, in 2015, all health care expenditures began phasing into irrevocability, having reached 100 percent irrevocability in 2017, which means that no healthcare expenditures less than the mandated spend can revert back to the employer.  In 2015, 60 percent of the funds were irrevocable; now in 2016, 80 percent of funds are irrevocable; and 100 percent of the funds are now irrevocable. Irrevocability applies to all health care allocations as required by law on an employee basis.  Irrevocability means the previous practice of unspent funds reverting back to the employer after 24 months is no longer permitted.  To understand the rules pertaining to revocable expenditures and how they count toward meeting the HCSO requirements, please see here.


A business has the discretion to charge a surcharge for any purpose as long as it is disclosed to the customer prior to purchase.  Businesses that choose to label a surcharge for health care expenses, HCSO, etc., will need to report to OLSE what percentage of that surcharge was allocated to health care expenditures and will need to report their expenditures, which need to be equal to or less than the amount collected.  If the amount collected from the surcharge for employee health care is greater than the amount spent on employee health care, the employer must irrevocably pay or designate an amount equal to that difference for employee health care. Surcharges are sales taxable.

The surcharge disclosures are designed to prevent consumer fraud; you should include any surcharges on your menu (including ones posted online) as well as label them on the bill representing the percentage or fee amount.  If you have a surcharge for “Healthy SF” or “Health Care”, your customers (and the City) expect 100% of that money to be spent on healthcare. If you have an “SF Employer Mandate(s)” surcharge and some portion of that surcharge is used to cover the cost of the ordinance, you will need to allocate the appropriate percentage of the surcharge to cover costs of the Health Care Security Ordinance and report that on your annual form to the City.

Affordable Care Act

The HCSO spending requirement in San Francisco is unrelated to ACA regulations, therefore, providing ACA-compliant health insurance may not meet HCSO spending requirements. HCSO applies to all employees who work 8 hours or more and the required spend is calculated based upon hours paid multiplied by the required hourly spend.  Therefore, the spend under HCSO could be greater than providing ACA-compliant insurance alone.

Starting in 2015, the ACA applied to employers with 100 or more full-time equivalents (FTEs), and now in 2016, employers with 50 or more full-time equivalents are required to provide health insurance for full-time employees (those working 30 hours or more a week) and their dependents, or pay a per month “Employer Shared Responsibility Payment” on their federal tax return.  The ACA has, however, made some significant changes to HRAs and their compliance. As stated above, HRAs are now considered excepted benefits, and these do meet the compliance requirements of the HCSO at the city level. The city has provided a list of FAQs discussing the Health Care Security Ordinance in conjunction with the Affordable Care Act.

The Affordable Care Act and San Francisco’s Health Care Security Ordinance

With employer responsibilities under the Affordable Care Act and recent amendments to San Francisco’s Health Care Security Ordinance taking effect, employers face a complicated compliance landscape in the coming years. The Golden Gate Restaurant Association has put together the following to outline coming changes and highlight issues and strategies pertinent to restaurant owners.

The Affordable Care Act (ACA)

While future of ACA provisions is unclear, the Small Business Health Options Program (SHOP) is available to employers with 100 or fewer employees.

For additional detail on employer responsibilities under the Affordable Care Act (ACA), the Kaiser Family Foundation put together a helpful infographic.

Key ACA Provisions Affecting Health Care Security Ordinance Compliance

As of January 1, 2014, employer-sponsored stand-alone health reimbursement accounts (HRAs) were no longer permitted under the ACA. This removes a popular compliance mechanism for many employers and also has implications for employees. Any employee with funds in an existing stand-alone HRA will be rendered ineligible for federal advance premium tax credits when purchasing coverage on the state marketplace, Covered California.

As of July 26, 2014, employees may permanently waive the unused portion of existing HRAs to gain eligibility for federal premium assistance without employers having to make replacement contributions (true per ACA and HCSO).

ACA Related Health Care Security Ordinance Compliance Changes

While stand-alone reimbursement accounts for major medical services are prohibited under the ACA, “excepted benefit” accounts are permitted. Excepted benefits include: adult vision and dental, certain single condition insurance plans and other non- “essential” health benefits. In 2014, the Office of Labor Standards Enforcement (OLSE) placed limits on allocating required expenditures to excepted benefit HRAs in excess of 20 hours per week for any covered employee and added reporting requirements. Due to the move to irrevocability, this requirement no longer applies.

Any employer that made contributions to an excepted benefits HRA in 2014 in excess of 20 hours per week per employee were expected to “true-up” at the end of the year those funds that weren’t fully expended by the employee. 

Frequently asked questions on the “true up” can be found here.

Using HRAs Going Forward

Health Reimbursement Accounts have been a popular compliance tool under the HCSO, especially among restaurants. Under current OLSE guidance there is no limit to using excepted benefit HRAs as long the expenditure is irrevocable.